POST HYSTERECTOMY HEMATOCRIT:

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1 POST HYSTERECTOMY HEMATOCRIT: A LEARNED ROUTINE, OR CLINICALLY USEFUL? Allison Parks CNA, Patrice Weiss M.D., Craig Koller M.Ed., Roger Lefevre M.D., Sharon Kimmel PhD.

2 In the field of medicine, many practices are based on tradition and continue to be passed down during residency training

3 Example: Standard Gynecology textbooks recommend obtaining a post operative hematocrit after a major surgical case. *Hysterectomy remains one of the most common surgical procedures performed by Obstetricians and Gynecologists, with an estimated 600,000 done annually.

4 Post hysterectomy hematocrits are usually ordered with the intent to identify intraabdominal bleeding that can cause anemia,requiring the transfusion of blood products.

5 However, factors need to be taken into account, such as: difficulty of procedure estimated blood loss pre operative CBC values

6 Study Aim: To identify clinical parameters negating the need for routine post-hysterectomy hematocrits.

7 In this era of managed care, routine laboratory testing practices should be examined

8 Study Goals: To compare differences in pre, intra, and postoperative clinical indicators for blood transfusion. To identify clinical parameters supporting the need for routine evaluation of a posthysterectomy hematocrit by a complete blood count (CBC) draw. To propose clinical parameters for ordering a post-operative CBC.

9 Study Design: A retrospective chart review of a random sample of 230 patients undergoing a trans-abdominal, vaginal or laparoscopic hysterectomy at our institution between January, 2004, and June, 2005.

10 Patients Excluded: oncology patients patients who had a code red during their hospital stay those whose stay was greater than 25 days

11 Collected Data: Plausible Confounding Factors: height, weight, history of cardiovascular disease, previous abdominal or pelvic surgery Pre-operative Factors: hemoglobin, hematocrit, heart rate, and blood pressure Intra-operative Factors: type of surgery, estimated blood loss, sponge count, input/output ratio, surgery time from incision to closure Post-operative Factors: time and values of hematocrit draw, blood pressure readings, morning after input/output ratio, and length of stay

12 Incidence of Transfusion: Overall = 10.4% Excluding oncology patients = 7.8% *Transfused patients had a longer length of stay than non-transfused patients. *Comparison of characteristics between transfused and non-transfused patients revealed no statistically significant differences between surgery type, age, weight, body mass index, and previous history of cardiovascular disease.

13 Pre -operative Transfusion N Mean SD p-value HCT Preadmission No Yes HBG Preadmission No Admit HR Yes No Yes Admit BP Systolic No Yes Admit BP Diastolic No Yes

14 Intra-operative Transfusion N Mean SD p-value Est. Blood Loss No Yes Lap sponge count No Yes Ortho sponge count No Yes Input-Output Ratio No Surgery time Yes No Incision to Closure Yes

15 First post-operative Transfusion N Mean SD p-value HCT Value Post-op No Yes HBG Value Post-op No HR Post-op BP Systolic Post-op (first on floor) Yes No <.001 Yes <.001 No Yes Floor BP Diastolic No Yes

16 Three main clinical indicators to aid post-operative CBC order decision: Pre-operative hemoglobin at, or less than 12g/dl. Pre-operative hematocrit at, or less than 36g/dl. Intra-operative blood loss of 425cc, or greater.

17 Patients Meeting Clinical Parameters Criteria Status Transfused Not Transfused Meets: Total Order CBC Does not Meet: Do Not Order CBC Total Sensitivity = 0.94 Specificity = 0.65 PPV=0.31 NPV=0.98

18 Conclusion A conscious approach to ordering postoperative lab tests will help slow the exponentially rising cost of health care. Objective clinical parameters may now aid the physician in his/her decision to order post-op testing.